Healthcare Provider Details

I. General information

NPI: 1750331070
Provider Name (Legal Business Name): PRASAD RAO K.D. PADALA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 04/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 FORT ROOTS DR 3J/NLR
NORTH LITTLE ROCK AR
72114-1709
US

IV. Provider business mailing address

2200 FORT ROOTS DR 3J/NLR
NORTH LITTLE ROCK AR
72114-1709
US

V. Phone/Fax

Practice location:
  • Phone: 501-257-2503
  • Fax: 501-257-2501
Mailing address:
  • Phone: 501-257-2503
  • Fax: 501-257-2501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number22329
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberE-7269
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License NumberE-7269
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License NumberE-7269
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: